Section 18.04.12.010 - DEFINITIONSAs used in this chapter:
01.Associate Member. Any individual who participates in an employee benefit plan (as defined in 29 U.S.C. Section 1002(1)) that is a multi-employer plan (as defined in 29 U.S.C. Section 1002(37A)), other than the following: a. An individual (or the beneficiary of such individual) who is employed by a participating employer within a bargaining unit covered by at least one (1) of the collective bargaining agreements under or pursuant to which the employee benefit plan is established or maintained; orb. An individual who is a present or former employee (or a beneficiary of such employee) of the sponsoring employee organization, of an employer who is or was a party to at least one (1) of the collective bargaining agreements under or pursuant to which the employee benefit plan is established or maintained, or of the employee benefit plan (or of a related plan).02.Expense. The cost incurred for a covered service or supply. A physician or other licensed practitioner orders or prescribes the service or supply. Expense is considered incurred on the date the service or supply is received. Expense does not include any charge:a. For a service or supply that is not medically necessary; orb. That is in excess of reasonable and customary charge for a service or supply.03.Geographic Area. A sector of land, as designated by the health carrier, which employers sitused within receive a specified rating factor. Geographic areas are limited to no more than six (6) designated areas, with no area being smaller than a county.04.Medically Necessary Service or Supply. One that is ordered by a physician and that the small employer carrier or a qualified party determines is: a. Provided for the diagnosis or direct treatment of an injury or sickness;b. Appropriate and consistent with the symptoms and findings of diagnosis and treatment of the insured persons injury or sickness;c. Is not considered experimental or investigative;d. Provided in accord with generally accepted medical practice;e. The most appropriate supply or level of service which can be provided on a cost-effective basis. The fact that the insured person's physician prescribes services or supplies does not automatically mean such service or supply are medically necessary and covered by the policy.05.New Entrant. An eligible employee, or the dependent of an eligible employee, who becomes part of an employer group after the initial period for enrollment in a health benefit plan.06.Pre-Existing Condition. a. A condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) months immediately preceding the effective date of coverage;b. A condition for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) months immediately preceding the effective date of coverage; orc. A pregnancy existing on the effective date of coverage.d. Genetic information will not be considered as a condition described in this definition in the absence of a diagnosis of the condition related to such information.07.Risk Characteristic. The health status, claims experience, duration of coverage, or any similar characteristic related to the health status or claims experience of a small employer group or of any member of a small employer group. Such characteristics can include family composition, group size, industry.08.Risk Load. The percentage above the applicable base premium rate that is charged by a small employer carrier to the rates of the small employer group, to reflect the risk characteristics of the small employer group.Idaho Admin. Code r. 18.04.12.010